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Privacy Statement and Consent
I hereby give my permission for Sydney Colorectal Associates Pty Ltd to pass on and to seek medical information from any medical practitioner, who has referred, treated or will treat me as long as the exchange of information is necessary for my medical treatment. I give my permission for Sydney Colorectal Associates to undertake tissue banking of pathology specimens from any procedures I may need to undergo; (de-identified) photography/recording of procedures I may need to undergo for educational, clinical and audit purposes; presentation of my (de-identified) clinical facts at educational or scientific meetings and in journals; and/or presentation of my (identifiable and linkable) clinical facts and discussion at multidisciplinary meetings that are presented for the purpose of optimising my clinical management.
I also give my permission for Sydney Colorectal Associates to use Medicare Online Claiming and/or electronic account transmission on my behalf when required, and I assign my right to Medicare benefits to the Practitioner who rendered the service/s.
I also give my permission for Sydney Colorectal Associates to send correspondence by post/SMS/email to help me maintain my health.
I acknowledge and understand that if there are any changes to the information provided above, it is my responsibility to inform Sydney Colorectal Associates to help me protect my privacy.
I acknowledge and understand that there may be out-of-pocket costs for services provided and that it is my responsibility to confirm with Medicare and/or my insurer (if any) as to my eligibility and the amount of any reimbursement, and if a procedure is necessary during my consultation, there may be an associated cost in addition to the standard consultation fee.
I consent to fees of $50 for a consultation and/or $200 for a procedure. If I need to cancel my appointment, I will provide at least 48 hours’ notice. If I fail to notify the clinic or do not attend my appointment, I understand that I will be charged the above fees, which are not eligible for Medicare rebates. Furthermore, I acknowledge that I will be restricted from making any future bookings until my account is settled.